Diabetes and Obesity in Latino Diabetes and Obesity in Latino ChildrenChildren

Leonel Villa-Caballero MD, PhDLeonel Villa-Caballero MD, PhD

Family and Preventive MedicineFamily and Preventive Medicine

School of MedicineSchool of Medicine

UCSDUCSD

AgendaAgenda

The current epidemic in the U.S. The current epidemic in the U.S. Risk factors for DM and obesityRisk factors for DM and obesity Diagnosis of diabetes and obesityDiagnosis of diabetes and obesity

Situation in LatinosSituation in Latinos Cultural differencesCultural differences Health disparities and sociodemographic statusHealth disparities and sociodemographic status

Successful Therapeutic strategiesSuccessful Therapeutic strategies Culturally sensitive approachCulturally sensitive approach

72

73

74

75

76

77

78

4.04.55.05.56.06.57.07.5

1990 1992 1994 1996 1998 2000

Prevalence of obesity, increased Prevalence of obesity, increased by 61% since by 61% since 19911991

More than 50% of US More than 50% of US adults are overweightadults are overweight

The Gene for obesity may be The Gene for obesity may be linked to the gene for type 2 linked to the gene for type 2 diabetesdiabetes

90 % of people with type 2 90 % of people with type 2 diabetes are overweightdiabetes are overweight

The Prevalence of Diabetes and The Prevalence of Diabetes and ObesityObesity

Pre

vale

nc

e (

%)

DiabetesMean body weight

kg

Year

No Data <4% 4%-6% 6%-8% 8%-10% >10%

Source: Mokdad et al., Diabetes Care 2000;23:1278-83; J Am Med Assoc 2001;286:10.

Diabetes Trends* Among Adults in the U.S.,(Includes Gestational Diabetes)

BRFSS, 1990,1995 and 20011990 1995

2001

What is diabetes?What is diabetes? Diabetes is an disease Diabetes is an disease of the metabolismof the metabolism

characterized by characterized by defective production/action ofdefective production/action of insulininsulin and the way body tissues uses and the way body tissues uses glucose glucose (sugar).(sugar).

The food we eat is broken down by digestive The food we eat is broken down by digestive juices to create polysaccharides, chylomicrons juices to create polysaccharides, chylomicrons and peptides and minerals to facilitate and peptides and minerals to facilitate digestion.digestion.

Diabetes is characterized by high glucose Diabetes is characterized by high glucose levels in the blood.levels in the blood.

What glucose levels are What glucose levels are normal?normal?

Normal: Normal: 70-100 mg/dL70-100 mg/dL AbnormaL :AbnormaL : >100mg/dL >100mg/dL

(“(“PrediabetesPrediabetes”)”) Diabetes :Diabetes : > 126mg/dL> 126mg/dL

ADA .Clinical practice recommendations. Diabetes in children .Diabetes Care 2006 Suppl 1;S26-27

How many types of diabetes How many types of diabetes are?are?

Type 1 DiabetesType 1 Diabetes Childhood or AdolescenceChildhood or Adolescence Usually Thin, thirsty, constantly tiredUsually Thin, thirsty, constantly tired Complete absence of insulin productionComplete absence of insulin production Tendency to develop Diabetic KetoacidosisTendency to develop Diabetic Ketoacidosis

Type 2 DiabetesType 2 Diabetes Mature Age(>40 years)Mature Age(>40 years) Overweight or Obese individualOverweight or Obese individual Progressive defects in insulin activity or productionProgressive defects in insulin activity or production Hyperosmolar stateHyperosmolar state

Gestational Diabetes* Gestational Diabetes* ((During Pregnancy)During Pregnancy)

ADA .Clinical practice recommendations. Diabetes in children .Diabetes Care 2006 Suppl 1;S26-27

Klein et al. In: Harris et al, eds. Diabetes in America, 2nd ed. 1995. Reiber et al. In: Harris et al, eds. Diabetes in America, 2nd ed. 1995. USRDS. Am J Kidney Dis. 1994;24:879.

Caucasian African-American Mexican-American

Prevalence of Complications in Type 2 Diabetes

40–59 years 60 years

0

20

40

Pat

ien

ts (

%)

New Cases of End-Stage Renal Disease

100

200

300

(per

mil

lion

/pop

ula

tion

)

0

Prevalence of Retinopathy in Type 2 Diabetes

Age Range of Amputations per 10,000 DM patients

0

40

80

120

160

200

Prevalence of overweight and obesity among Prevalence of overweight and obesity among school-age children in global regionsschool-age children in global regions

05

1015202530354045

Pre

vale

nce (

%)

OverweightObese

Obesity and overweight defined by IOTF criteria. Children aged 5-17 years. Based on surveys in different years after 1990. Source: IOTF, 2004)

Prevalence of childhood overweight, U.SPrevalence of childhood overweight, U.S..

Obesity DefinitionObesity Definition Excessive adipose tissue located in different organs in Excessive adipose tissue located in different organs in

the human bodythe human body. . This abnormality is caused by an This abnormality is caused by an imbalance between the caloric intake of energy (Kcal) imbalance between the caloric intake of energy (Kcal) and energy consumed or expended (MJoules/day) with and energy consumed or expended (MJoules/day) with deleterious effects on general healthdeleterious effects on general health

IOTF and WHO have documented epidemic levels of IOTF and WHO have documented epidemic levels of obesity(James 2001)obesity(James 2001)

Obesity is associated with atherosclerosis, Obesity is associated with atherosclerosis, hypertension, diabetes, cancer, cerebrovascular hypertension, diabetes, cancer, cerebrovascular disease, osteoarthritis and osteoporosis (Roth and disease, osteoarthritis and osteoporosis (Roth and Qiang,2004)Qiang,2004)

Obesity Is Caused by Long-Obesity Is Caused by Long-Term loss of Energy BalanceTerm loss of Energy Balance

FatFatStoresStores

CDC Charts for BMI, boys and girls CDC Charts for BMI, boys and girls ages 2-20 ages 2-20

Undernutrition :< 5th BMI percentile

Normal: 6-84th BMI percentile

Risk of overweight :>85th-94th BMI

percentile

Overweight: > 95th BMI percentile

Prevalence of MS in adolescents Prevalence of MS in adolescents 12-18 years in the U.S. 1988-200012-18 years in the U.S. 1988-2000

Duncan GE : Diabetes care 2004;27:2438-2443

Which are the Risks Factors for Which are the Risks Factors for Diabesity?Diabesity?

Increase in Visceral Increase in Visceral Adiposity, ObesityAdiposity, Obesity

Sedentary LifestyleSedentary Lifestyle Genetic Genetic

predisposition* predisposition* Positive Family Positive Family History of Diabetes History of Diabetes

AcculturationAcculturation

Sedentary LifestyleSedentary Lifestyle

012345678

Fatness, Fitness and Fatness, Fitness and Cardiovascular Disease Cardiovascular Disease

MortalityMortality

Lean<16.7%

Rel

ativ

e R

isk

of C

VD

Mor

talit

y

Body Fat Category (% Weight as Fat)Lee et al. Am J Clin Nutr 1999;69:373.

Normal16.7%-24.9%

Obese>25%

Aerobically fit

Unfit

1

1.5

2

2.5

Re

lati

ve

Ris

k

0-1 2 a 5 6 a 20 21 a 40 40 +

Hours TV/ week

TV watching and Diabetes-Obesity risk

DiabetesObesity

Every 2 hrs of TV watching Every 2 hrs of TV watching increases increases 23% Obesity

13% Diabetes p< 0.001p< 0.001

Mu et AL,JAMA 2003; 289: 1785-1791Mu et AL,JAMA 2003; 289: 1785-1791

Food choices and Super-sizesFood choices and Super-sizes Plenty of Saturated Plenty of Saturated

Fats and Fats and CarbohydratesCarbohydrates

Huge Portions!Huge Portions! Cheap, available food Cheap, available food

everywhere everywhere Early Start!Early Start!

(357gms)(357gms)960 Cal960 Cal46g Carbs 46g Carbs 63 g Fat63 g Fat1420 mg Na1420 mg Na

(116gms)(116gms)370 Cal 370 Cal 43g Carbs43g Carbs20gFat 20gFat 240 mg Na240 mg Na

Sodas vs. other beveragesSodas vs. other beverages

Population Projections of the United States by Age, Sex, and Hispanic Origin: 1995 to 2050. Bureau of the Census, 1996.

US Latino Population, 1995 US Latino Population, 1995 to 2050to 2050

Latinos will add the largest number of Latinos will add the largest number of people to the US population each yearpeople to the US population each year

By 2020, will add more people to the By 2020, will add more people to the US population than all other ethnic US population than all other ethnic groups combinedgroups combined

Of the increase of 1.3 million, 800,000 Of the increase of 1.3 million, 800,000 was because of natural increase was because of natural increase (births minus deaths) and 500,000 was (births minus deaths) and 500,000 was because of immigration. because of immigration.

The Racial and Ethnic Diversity of the The Racial and Ethnic Diversity of the US Population Will Continue to IncreaseUS Population Will Continue to Increase

3.8

13.5

5.4

50.1

24.4

8.012.712.6

69.4

17.8

61.3

14.6

0

10

20

30

40

50

60

70

80

2000

2020

2050

% o

f Tot

al P

opul

atio

n

US Census Bureau. US interim projections by age, sex, race, and Hispanic origin. 2004. Available at:http://www.census.gov/ipc/www/usinterimproj/. Accessed on December 21, 2005.

Non-HispanicWhite

Hispanic(of any race)

African American

Asian

Cultural Differences. The Cultural Differences. The Latino CaseLatino Case

45% of Latino patients report communication 45% of Latino patients report communication problems-not just the language-.problems-not just the language-.

Unwillingness to seek care due to language Unwillingness to seek care due to language barriersbarriers Poor understanding of the disease and treatmentPoor understanding of the disease and treatment Defective communication between Health care Defective communication between Health care

provider and patientprovider and patient Culture is more than only speak a different Culture is more than only speak a different

language (gender roles, dietary habits, language (gender roles, dietary habits, emotional issues, specific concerns about emotional issues, specific concerns about treatment)treatment)

Cultural Differences. The Cultural Differences. The Latino CaseLatino Case

Family dynamics and disease (Gender roles, Family dynamics and disease (Gender roles, machismo)machismo)

Personal values: Personal values: respeto respeto (respect),(respect),simpatiasimpatia(kindness) (kindness) interés personal interés personal (interest)(interest)

Limited economic resources, low rate of health Limited economic resources, low rate of health insurance insurance

Insulin fear and rejection*Insulin fear and rejection* Myths and misconceptions (CAM use)Myths and misconceptions (CAM use) DepressionDepression

Practical strategies to solve Practical strategies to solve language barrierslanguage barriers

Bilingual/Bicultural staffBilingual/Bicultural staff InterpretersInterpreters Language skills training for staffLanguage skills training for staff Written translationsWritten translations Phone-based servicesPhone-based services Identify community leadersIdentify community leaders

Obesity Treatment PyramidObesity Treatment Pyramid

DietDiet Physical ActivityPhysical Activity

Lifestyle ModificationLifestyle Modification

PharmacotherapyPharmacotherapy

SurgerySurgery

Goals of Medical Nutrition Goals of Medical Nutrition TherapyTherapy

Achieve blood glucose goalsAchieve blood glucose goals Achieve optimal lipid levelsAchieve optimal lipid levels Provide appropriate calories for:Provide appropriate calories for:

- Reasonable weight- Reasonable weight

- Normal growth and development- Normal growth and development

- Pregnancy and lactation- Pregnancy and lactation Prevent, delay or treat nutrition-related Prevent, delay or treat nutrition-related

complicationscomplications Improve health through optimal nutritionImprove health through optimal nutrition

Diabetes Care 22(1):S42-S45,1999

What is a healthy school environment?What is a healthy school environment?

Impact of Weight Loss on Risk Impact of Weight Loss on Risk FactorsFactors~5%~5%

Weight LossWeight Loss5%-10%5%-10%

Weight LossWeight Loss

HbA1cHbA1c

Blood PressureBlood Pressure

Total CholesterolTotal Cholesterol

HDL CholesterolHDL Cholesterol

TriglyceridesTriglycerides

1. Wing RR et al. Arch Intern Med. 1987;147:1749-1753.

2. Mertens IL, Van Gaal LF. Obes Res. 2000;8:270-278.

3. Blackburn G. Obes Res. 1995;3 (Suppl 2):211S-216S.

4. Ditschunheit HH et al. Eur J Clin Nutr. 2002;56:264-270.

1

2

3

3

1

2

3

3

4

Diabetes Prevention ProgramDiabetes Prevention Program

0

2

4

6

8

10

12

Placebo Metformin Lifestyle modification

Cas

os

/ 100

per

son

a-an

os 2.8 year follow-up

31% *

58% *

*All pair-wise comparisons significantly different by group sequential log-rank testThe Diabetes Prevention Program Research Group. New Engl J Med 2002;346:393-403Ann Intern Med 2005;142:323-332.

-7

-6

-5

-4

-3

-2

-1

0

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Decreasing Television Viewing Leads Decreasing Television Viewing Leads to improved Body Mass Index in to improved Body Mass Index in

ChildrenChildren

6-monthintervention

Robinson JAMA 1999;282:1561.

Control

Change in BMI (kg/m2)

6-monthintervention

Control

Change in TV viewing (h/wk)

P=0.002

P<0.001

-25

-20

-15

-10

-5

0

Effect of Decreasing Sedentary Effect of Decreasing Sedentary Activities vs Increasing Physical Activities vs Increasing Physical

Activities on Body Weight in Children Activities on Body Weight in Children 6-12 Years Old6-12 Years Old

0Time (months)

Decreased Sedentary Activity

Cha

nge

in P

erce

nt O

verw

eigh

t

Increased Physical Activity

Epstein et al. Health Psychol 1995;14:109.

4 8 12

Guidelines for Increasing Guidelines for Increasing Physical ActivityPhysical Activity

AssessmentAssessment1) Medical and psychological readiness1) Medical and psychological readiness

2) Physical limitations2) Physical limitations

3) Current activities3) Current activities

4) Barriers to activity4) Barriers to activity

Develop physical activity planDevelop physical activity plan Start activity slowly and gradually increase Start activity slowly and gradually increase

planned aerobic activity to 200 min/wkplanned aerobic activity to 200 min/wk Enhance complianceEnhance compliance

Programmed vs lifestyle activityProgrammed vs lifestyle activity At-home vs onsite activityAt-home vs onsite activity Multiple short bouts vs single long bout of activityMultiple short bouts vs single long bout of activity

www.diabetes.org 1-800-DIABETES

34

Recommendations T1 Diabetes :

• Check hypoglycemic unawareness, intellectual maturity and self -control

• Glucose control goals

• Microalbuminuria > 10 y if DM1>5 a.

• Hypertension if SBP-D >percentila 90 age and height. Drugs: ACE’s

• Eye exam >10a.

• If LDL >160mg/dL initiate drug therapy

ADA .Clinical practice recommendations. Diabetes in children .Diabetes Care 2006 Suppl 1;S26-27

www.diabetes.org 1-800-DIABETES

35

Recommendations for T2 Diabetes diagnosis in children

• Overweight (>BMI percentile 85 th o more than 120% of ideal BW)– Family History of Diabetes

– Ethnic group AA, NA, HA o de las IP

– >10 y puberty

– Acantosis nigricans, polycistic ovary, hypertension, hyperlipidemia

• Every 2 years fasting gluose*

ADA statement: Diabetes 2 in Children and adolescents .Diabetes Care 2000;23:281-289

SummarySummary

Diabetes and obesity are very common Diabetes and obesity are very common among Latinosamong Latinos

Latinos have higher rates of diabetic Latinos have higher rates of diabetic retinopathy, ESRD, amputationsretinopathy, ESRD, amputations

There are genetic and environmental There are genetic and environmental factors that influence the prevalenceof factors that influence the prevalenceof obesity metabolic syndrome and diabetes obesity metabolic syndrome and diabetes among Latinos among Latinos

SummarySummary

There are cultural differences between There are cultural differences between Latinos and other ethnic groups that may Latinos and other ethnic groups that may impact health outcomesimpact health outcomes

A culturally-sensitive approach is A culturally-sensitive approach is necessary to overcome barriersnecessary to overcome barriers

Appropriate diet and physical activity Appropriate diet and physical activity must be encouraged by a multi-must be encouraged by a multi-disciplinary teamdisciplinary team